Basic Information
Provider Information | |||||||||
NPI: | 1669755799 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILIA DENTAL SPRINGFIELD 3 LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAMILIA DENTAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2050 E ALGONQUIN RD | ||||||||
Address2: | SUITE 610 | ||||||||
City: | SCHAUMBURG | ||||||||
State: | IL | ||||||||
PostalCode: | 601734144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8889884066 | ||||||||
FaxNumber: | 8474967202 | ||||||||
Practice Location | |||||||||
Address1: | 802 N 9TH ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 627026309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8889884066 | ||||||||
FaxNumber: | 8474967202 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2011 | ||||||||
LastUpdateDate: | 09/26/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | H AZAD | ||||||||
AuthorizedOfficialFirstName: | KOUSHAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8889884066 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DMD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 019026920 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |   |
No ID Information.